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Twenty-first century science underpinned the rapid global response to COVID-19, identifying the causal pathogen, sequencing the SARS-CoV-2 genome, developing vaccines and initiating clinical trials, within 9 months of first appearance. Although in tackling the immediate consequences of the pandemic countries responded to science in different ways, every nation now grapples with the economic consequences and the question of where to focus investment. Here, we argue that insights from 21st century science can also lead the way to economic recovery. These indicate that there should be a prime focus on healthy populations resilient to unexpected challenges and that this is to a large extent dependent on maternal, neonatal and child health (MNCH). Recovery from COVID-19 offers a unique opportunity to target investment on MNCH.
Post-COVID economic recovery will have to take place against the continuing backdrop of the growing population prevalence of chronic non-communicable diseases (NCDs) that are progressively crippling health systems, societies and economies. Thus, in 2019, the USA witnessed a reversal of the rise in life expectancy and healthy longevity that characterised previous decades. Pre-COVID policies were unable to tackle these challenges; hence, restoring the status quo appears to be a doomed strategy. However, science shows clearly that MNCH is of pivotal importance to preventing and reducing the population prevalence of physical and mental NCDs.1 For example, babies born preterm, are growth restricted or born to mothers who are undernourished, overweight or with diabetes represent a large and growing proportion of all births and are at substantially increased odds of developing hypertension, diabetes, renal impairment, heart disease and other chronic NCDs in adult life.2 In high-income countries, around two-thirds of adults are now overweight or obese. Preterm births are rising, with an estimated global rate of 10.6% in 2014.3 The prevalence of malnutrition among pregnant women in Africa is estimated at 23.5% (95%CI 17.72 to 29.32).4 Intergenerational transmission is worsening these problems, as a woman born preterm is more likely to deliver preterm, and the daughter of an obese mother is likely to become obese herself. Approaches focused on MNCH would benefit human potential through multiple determinant pathways that include education, empowerment, mental well-being and personal resilience, in addition to health. Uniquely, investment today will amplify returns across successive generations.
The dominant view of economic recovery is that it must reverse the dramatic fall in gross domestic product (GDP) caused by the response to the pandemic. However, GDP is a flawed biomarker of a country’s well-being.5 GDP represents the monetary value of goods and services produced over a period, but it does not take their impact on population health into account, though this is crucial to economic stability. Thus, GDP includes the outputs of the tobacco and fast-food industries but does not subtract the costs of their contributions to cancer and obesity. GDP does not incorporate the contributions to the economy of childbearing and child rearing, though these are powerful determinants of physical and mental well-being, and adult productivity. Likewise, the manufacture of infant formula contributes to GDP, but breast feeding, which has major, quantifiable benefits on the health of mothers and babies, does not; and perversely, women who stop work to breastfeed incur a financial penalty. A single metric incorporating the negative impacts of products and services on population health, and the positive impacts of healthy pregnancies and childcare, would be a better biomarker of a country’s well-being than GDP and a better metric on which to base post-COVID recovery.
There are other pressing reasons for a focus on MNCH. The economic models of the late 19th and 20th centuries were at odds with the great social movements that arose in parallel, which included women’s suffrage and reproductive and child rights. The extractive economics implicit in these models perpetuated gender-based and age-based inequities, enabling some nations and a minority of the world’s population to accumulate enormous wealth, while many billions remain impoverished. This conflict continues, exemplified, for example, by the undermining of the WHO, the promotion of marketised healthcare and the resistance to healthcare reform in the USA, conditions that amplify gender-based and age-based inequities. Initial responses to COVID-19 are widening them still further. Thus, in the UK, conventional economic thinking led to spending over £400 million on stimulating consumption and reopening pubs and restaurants before schools, and the US Census Bureau reports that working mothers have had to withstand the worst of COVID-19 restrictions. The realisation that many pre-COVID industries are unsustainable should be a trigger to rethink the value to societies of healthy women and children, and to promote this through targeted investment.
Advocating for investment in MNCH is not new, but discourse to date has been limited on four principal counts. First, most suggested interventions centre on medical constructs—clinic visits, screening, identification and treatments—that ignore the wider environmental, attitudinal and socioeconomic determinants of MNCH. Second, the justifications for investment in MNCH have focused predominantly on short-term outcomes, such as infant mortality and morbidity, rather than the longer-term and transgenerational benefits to population health and the economy. Third, as explained previously, many activities that benefit MNCH are unmeasured, and hence unrecognised and unvalued; for example, the inclusion of unpaid household work alone—which sustains the remunerated industries—would increase GDP from between 15% and 70%,depending on the country and method of calculation.6 Fourth, the science of the developmental origins of health and disease has advanced from epidemiological associations that provided a limited basis for policy to detailed understanding of causal pathways from exposures and experiences in early life to later health or disease. In 1855, Frederick Douglass, a former slave, said, ‘It is easier to grow strong children than to repair broken men’, a prescient articulation of the scientific basis for focussing policies on MNCH. Yet, in what future generations will see as unimaginable folly, current economic thinking discounts and, in many respects, actively detracts from MNCH.
It is time to take stock and to take action to promote investment in MNCH at both individual and societal levels.7 Societies with the best chance of a strong future will be those with healthy populations that have resilience to future shocks. This means ascribing value to and investing in MNCH. There are many powerful policies to consider. Six months of statutory paid leave on a ‘use it or lose it’ basis for each parent in a child’s first year would improve breast feeding, family cohesion and gender equity. Targeted parenting support and skills training would benefit children directly and reduce the substantial economic cost of maltreatment. Universal national healthcare systems would eliminate the hefty transactional costs and inherent inequities of marketised models that disproportionately disadvantage women and children. A global road map for universal education would empower billions, particularly girls, and reduce crippling personal and national dependencies. These proposals will appear unattainable to many and will be countered and fought, as was every great movement in history. Investing in MNCH, as a prime strategy for post-COVID recovery, is not only the right thing to do but also provides a unique opportunity to reframe economic thinking for a sustainable future. We ask readers to call on their professional organisations and parent and family advocacy groups to promote investments to policy-makers that target MNCH.
Contributors All authors contributed equally to this work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests NM is immediate past president of the UK Royal College of Paediatrics and Child Health and current president of the UK Medical Women’s Federation; the views expressed are her own.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
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